After a speech on AIDS at the National Press Club in
Washington in late March 1987, reporters pressed U.S.
Surgeon General C. Everett Koop whether a pregnant woman
with AIDS should be counseled about abortion. Koop
responded that even though he would never personally
recommend an abortion, the woman should receive advice on
abortion because of the risk of transmitting the disease to
her child. His offhand comment, distorted further, he
complained, by the press, was interpreted by many abortion
foes as a betrayal of his anti-abortion principles. Coming
not long after the release of his report on AIDS, a report
that had incensed conservatives with its frank discussion
of sexuality and condom use, his remark further alienated
his former supporters. Abortion proved the most vexing
issue of Koop's tenure because it blurred the boundary
between public health and personal moral choices.

Koop was exasperated by criticism that he had
abandoned his stance on abortion, which as an evangelical
Christian he had strongly opposed throughout his life. "My
concern for the unborn followed as the night the day my
concern about the newly born," he explained. "How could I
ever accept the destruction of the unborn after a career
devoted to the repair of imperfect newborns, knowing the
joy and fulfillment they brought to their families?"
Moreover, he feared that the abortion of unwanted babies
prepared the moral ground for the decimation of other
groups who often imposed a burden on their caretakers and
on society, namely persons with disabilities and the
elderly, through euthanasia and assisted suicide. Koop
opposed these measures as much as he opposed abortion.
After the U.S. Supreme Court's Roe v. Wade decision
legalized abortion in 1973, Koop made his concerns public
in a book, The Right to Live, The Right to Die, and in
Whatever Happened to the Human Race?, a multimedia project
of five films and complementary lectures and seminars he
produced together with the theologian Francis Shaeffer.
Although he continued to perform operations, Koop assigned
patients who required long-term care to other doctors while
he lectured against abortion and euthanasia across the
country. In his own mind, if not in the minds of his
conservative critics, his opposition to abortion was
unquestioned.

For Koop, refusing to take an official stand on
abortion was consistent with his anti-abortion beliefs. He
had been chosen as Surgeon General by President Ronald
Reagan, and had been supported by conservatives, with the
expectation that he would use his office to promote an
anti-abortion agenda. Yet, while he continued to express
his views on abortion privately before pro-life and
evangelical religious groups, including pro-life audiences
invited by President Reagan to the White House, he avoided
the issue in his official function as Surgeon General. As
Koop explained, he conceived of abortion as a moral issue
that could only be resolved through moral inquiry and
reform, not as a public health issue that was amenable to
medical or scientific solutions.

Pro-life activists continued to misunderstand and,
Koop charged, in some cases deliberately to misconstrue his
position on abortion during his final two years in office.
They felt confirmed in their view that Koop was a traitor to
the pro-life cause. Koop himself, on the other hand, became disillusioned with
their single-minded approach to politics. Tension between
pro-life activists and Koop heightened when in 1988 President
Reagan asked Koop to prepare a Surgeon General's report on
the effects of abortion on women's health. During two
terms in office, Reagan had done little to deliver on his
campaign promise to restrict abortion. With the end of his
presidency in sight, he sought to affirm his pro-life
values by focusing on the psychological and physical
effects of abortion on women, which he thought were
pronounced enough to provide a rationale for reversing the
nation's abortion laws and policies.

Koop accepted the assignment with great reluctance,
suspecting that Reagan was concerned more with appeasing
his political base than with improving women's health. As
had become Koop's practice in drafting reports, he
personally interviewed experts, activists, and people
directly affected on both sides of the abortion
controversy. He found that, even more so than in the
debate over AIDS, the politics of abortion skewed
scientific approaches. Researchers allowed the design of
their studies as well as their results to be influenced by
their moral and political commitments in regard to
abortion. Koop concluded that there was no unbiased,
rigorous scientific research on the effects of abortion on
women's health that could serve as the basis for a Surgeon
General's report on the issue. He had hoped to explain his
conclusion to the president in person, but the issue was
overtaken by the presidential election of November 1988,
and by Reagan's preparations for his departure from office.
Koop was able only to deliver a letter to White House
staffers, dated January 9, 1989, in which he stated that
"the available scientific evidence about the psychological
sequelae of abortion simply cannot support either the
preconceived notions of those pro-life or those pro-choice."
Koop's careful qualification that there was at
present no objective scientific data to help decide the
issue was lost in some media reports, which announced,
inaccurately, that the Surgeon General had found no
evidence for abortion's harmful effect on women's health.
Pro-life groups responded to these reports by denouncing
Koop for apparently endorsing abortion rights.

Koop's refusal to take a pro-life position in the
debate over the health effects of abortion on women made
him unsuitable in the eyes of many conservatives for the
position of Secretary of Health and Human Services in the
new administration of President George H. W. Bush, a
position in which Koop had expressed interest. When Bush
did not offer him the job and sent signals that his
services were no longer desired--for instance by firing his
main assistant--Koop decided to leave office one month
before the end of his second term. The issue that had
dominated Koop's confirmation as Surgeon General--abortion--also
heralded his exit from government service.

If abortion was the most controversial of the issues
involving reproduction, sexuality, and family health, it
was not the only such issue for Surgeon General Koop, nor
was it the one to which he devoted most of his time and
energy. To Koop, his own family had been the most
formative influence on his life, character, moral values,
and sense of self. He saw the health of the family, so
essential to an individual's well-being, under threat from
several directions, not only from the high number of
abortions but also from health hazards that he, as the
nation's top public health officer, could address by
encouraging scientific study, disseminating health
information, and fostering public debate and consensus.
These health hazards included inadequate maternal and child
health care as well as the poor diet of many Americans,
both of longstanding concern to the federal government.
Koop made these issues the subject, respectively, of the
"Surgeon General's Workshop on Breastfeeding and Human
Lactation," held in June 1984, and The Surgeon General's
Report on Nutrition and Health, published in 1988. Koop
addressed another well-established area of federal social
and health policy, the welfare and health needs of the
elderly, in his "Surgeon General's Workshop on Health
Promotion and Aging," held in March 1988. During the
workshop participants stressed that the later years of life
were not just a prelude to death, but provided
opportunities to share expertise and experience with
younger generations in ways that could make the elderly a
productive asset to their families and communities--the
emphasis also of the many speeches Koop devoted to the
medical, psychological, and social ramifications of the
aging process.

In addition, Koop saw threats to family health arising
from hazards that previously had not been a matter of
federal health policy, namely from domestic and other forms
of violence, such as pornography, child sexual abuse, drunk
driving, and preventable household accidents. Koop
acknowledged that these problems "were usually beyond the
purview of the Surgeon General" because they were most
often approached as problems of law and law enforcement, of
private morality, and of free speech. But Koop was
prepared to expand the definition of public health, and
thus the scope of his office, to include these problems and
to subject them to public health methods, namely
epidemiological study, disease prevention strategies, and
health promotion information.

In October 1985, Koop convened a "Surgeon General's
Workshop on Violence and Public Health" that examined what
he considered an epidemic of violence that claimed an
estimated four million victims each year, most of them
children, women, and the elderly. The workshop was
concerned particularly with the role of violent images
conveyed by popular entertainments and by the media in
fostering violence, as well as with the long-term
psychological effects of violence on victims, such as the
suspected propensity of victims of violence to turn violent
themselves. Participants also explored ways in which the
medical, nursing, psychological, and social service
professions could better prevent violence and help victims.
As part of a task force on pornography assembled by U.S.
Attorney General Edwin Meese III, in June 1986 Koop
organized a "Surgeon General's Workshop on Pornography and
Public Health" that explored the connection between the
widespread availability of pornography and the incidence of
domestic violence and sexual abuse. He issued a Surgeon
General's Letter on Child Sexual Abuse in 1988. His last
initiatives as Surgeon General were designed to reduce the
number of preventable accidents, both accidents caused by
drunk driving, the subject of a Surgeon General's workshop
held in December 1988, and the large number of household
accidents, especially those involving children.

To address these issues and health challenges facing
the family and the nation, Koop favored not only stronger
laws and governmental measures--such as stricter drunk
driving laws and more explicit warning labels on
cigarettes--he also encouraged patients, their families,
and others directly affected by disease or chronic health
problems to organize in mutual aid and self-help groups,
the subject of a workshop Koop organized in September 1987.
His successors have built upon Koop's expansive vision of
the responsibilities of the U.S. Surgeon General by
addressing a widening range of public health issues,
including organ donation, mental health, suicide
prevention, sexual health, and obesity.